COVID-19 Questionnaire

 
 

Please Complete the Following Questionnaire Prior to Your Visit

(All Fields Are Required)

    Have you tested positive for COVID-19 in the past month? Or have you been advised by your physician or local public health department to self-isolate?

    Do you have or have you recently had (in the past 14-21 days) any of the following symptoms:

    Fever above (38°C) or feeling hot, chills/feverish?

    Shortness of breath or other difficulties breathing?

    Cough or worsening of a chronic cough?

    Flu-like symptoms such as stomach upset, diarrhea, headache, fatigue or sore throat?

    Recent alteration or loss of taste or smell?

    Any new, unusual symptoms? e.g. feeling unwell, or sudden onset of runny nose?

    Have you been in contact with anyone with confirmed COVID-19 or with any of the above symptoms of possible COVID-19 in the past 14 days?

    Have you traveled in the past 14 days out of the country or to any COVID-19 hot spots?